Providers’ Stigmas and the Effects on Patients with Opioid Use Disorder: A Scoping Review

Introduction One of the most prevalent, dangerous stigmas in health care is the complex bias toward patients with opioid use disorder (OUD). This stigma damages the vital patient–provider relationship, further perpetuating the opioid epidemic. Purpose Unfortunately, research on the relationship between OUD and provider stigma is greatly lacking. To fill this gap, the present in-depth study undertakes a scoping review of research on providers’ stigma toward OUD in order to determine how enacted stigma affects treatment plans. Methods Four databases were used to identify articles published from 1999 to 2021. A comprehensive search strategy was developed through a collaborative process between the researchers and a medical librarian. The researchers used the methodological framework developed by Arksey and O’Malley (2005) and expanded upon by Levac et al.(2010) to chart study characteristics and themes. Results A total of 196 search items were retrieved. After de-duplication (n=31), remaining articles were screened based on the inclusion and exclusion criteria detailed in the protocol. After both a title/abstract review and full-text review, an additional 158 articles were removed. This yielded a total of seven articles. Three main themes were identified in the literature: (1) rural–urban differences in bias; (2) provider concern regarding legal implications and regulatory concerns; and (3) the belief that OUD is a moral failing rather than a medical diagnosis. Implications Additional research should further analyze prescribed treatment plans for patients with OUD and utilize this information to create future considerations aimed at reducing opioid-related stigma in healthcare in Appalachia.


INTRODUCTION
Bias and stigmas in healthcare have been a hot topic over the past couple of years.Diversity and inclusion boards have popped up at nearly every academic institution and hospital.Race, gender, sexuality, and disabilities have been at the center of every conversation.However, one of the most prevalent and critical stigmas remains unaddressed.The lack of scrutiny regarding this tangible bias is a missed opportunity for truly improving healthcare in Appalachia.
Stigmas in healthcare shape the access and quality of care patients receive.Opioid use stigma is a complex concept that further perpetuates the opioid epidemic.To improve this disparity, it is essential to examine the literature and understand the evidence provided by these studies.Unfortunately, research on the relationship between opioid use disorder and provider stigma is greatly lacking which has created the need for this in-depth analysis.
Researchers will investigate the evidence available in the peer-reviewed literature in order to better understand the ways provider bias manifests into enacted stigma in Appalachia.We are particularly interested in research in Central Appalachia (Tennessee, Kentucky, West Virginia, and Virginia), as the region is a hub for the opioid epidemic.The objective of this scoping review is to call attention to the egregious disparities in healthcare affecting those with opioid use disorder.

STUDY OBJECTIVES
The objectives of this review are as follows: • Analyze and summarize the results of peer-reviewed literature examining the stigma associated with Opioid Use Disorder and how these stigmas affect providers' prescribed treatment plans.
• Categorize the effects of each factor and investigate any developing patterns.
• Provide recommendations to decrease the social stigma associated with Opioid Use Disorder and prevent any bias in providers' treatment plans.• Determine areas in which further research is necessary.

METHODS AND ANALYSIS
The researchers will conduct a scoping review to examine the literature on how health care providers' stigmas affect prescribed treatment plans in those with Opioid Use Disorder.In particular, the researchers aim to focus on literature in the Appalachian region of the United States.The researchers investigating this question are meant to thematically examine the literature in order to understand the connection between providers' stigmas of opioid use disorder and provider choice and patient care.
The researchers chose a scoping review methodology because of its goal to "map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps" within the published literature 3 .The researchers will use the methodological framework developed by Arksey and O'Malley and expanded upon by Levac et al. 4 5 .This method will include (A) identifying and clearly defining the research question; (B) searching and identifying relevant studies; (C) study selection; (D) charting the data both quantitatively and thematically; and (E) summarizing and reporting the results.

Defining the Research Question
Since scoping reviews require addressing a broad research question in order to synthesize the breadth of the literature, it is important to clearly define the variables that will be searched.Through consultation and iterative revisions, the research team developed one broad research question: What are providers' stigmas and prescribed treatment plans for those with opioid use disorders in Appalachia?Consistent with the Levac et al model, researchers have defined and operationalized study concepts and target populations.For this review, opioid use disorders will be defined as disorders related to or resulting from abuse or misuse of opioids.Synonyms will include terms such as opioid, opium, morphine, heroin, and substance abuse.Stigma will be defined as a perceived attribute that is deeply discrediting and is considered to be a violation of social norms (MeSH).Stigma will include but will not be limited to terms such as social stigma, bias, prejudice, attitudes, and marginalization.Health care providers will be defined as those working in the provision of health services, whether as individual practitioners or employees of health institutions and programs, whether or not professionally trained, and whether or not subject to public regulation (MeSH).This will include terms such as health personnel, health worker, practitioner, health professional, dentist, physician, doctor, clinician, therapist, pharmacist, and provider.Finally, Appalachia is defined as the geographical area of the United States which includes portions of Alabama, Georgia, South Carolina, North Carolina, Kentucky, Tennessee, West Virginia, Virginia, Maryland, Pennsylvania, Ohio, and New York (MeSH).

Searching and Identifying Relevant Studies
A comprehensive search strategy will be developed through an iterative and collaborative process among the researchers and the medical librarian.Relevant studies will be identified through searching MEDLINE PubMed, PsycInfo (EBSCOhost), CINAHL with Full Text (EBSCOhost), and Web of Science (Clarivate).The coverages of each database are described in Table 1.The researchers selected these databases based on institutional availability, alongside the breadth of discipline coverage, which spans healthcare, public health, and social sciences disciplines.These sources will be searched using a combination of relevant search terms and subject headings that were developed through an initial scan of the literature using MEDLINE PubMed and sentinel articles.The terms, detailed in Table 2, will be adapted to match the syntax of each electronic database.To ensure this scoping review captures the full extent of the literature, extensive hand searching of reference lists will be completed on all included studies.Finally, according to the National Association of Counties (NACo) AND Appalachian Regional Commission (ARC) white paper, "Opioids in Appalachia The Role of Counties in Reversing a Regional Epidemic" the opioid epidemic began in 1999 (NACo & ARC, 2019).Therefore, the search will include a date limit from 1999 to present.

Search Strategy Data Management Plan
The medical librarian will create a table recording essential information, including but not limited to date searches were conducted, search strategies, and number of search results.The resulting citations will be exported to EndNote Citation Management Software.The Groups function will be used to sort references by database.Since the Groups function keeps a record of citations, this process will act as a backup to the table mentioned previously.The EndNote library will be copied, and the deduplication function of EndNote will be used to reduce the number of citations to review.Both EndNote libraries will be saved as individual files in order to maintain a record of the deduplication process and reduce overall error.After the initial title/abstract review has been completed, the medical librarian will pull and attach PDFs to the EndNote Library so full-text review can be completed.In order to ensure continuous access, the medical librarian will keep remote copies of all files using OneDrive.

Study Selection Inclusion and Exclusion Criteria
The following inclusion criteria will be used to lead the search and will also be used to review articles: (1) The study focuses on patients with Opioid Use Disorder; (2) The study focuses on stigmas and bias from healthcare practitioners; (3) The study is based in Appalachia; (4) The study is published in a peer-reviewed journal; (5) The study was published between 1999 -2021; and (6) Because of the Appalachia regional focus of this review, literature will be limited to English language.
The exclusion criteria that have been identified are: (1) The study focuses on non-opioid related substance abuse; (2) The study focuses on community stigma; and (3) The study was published prior to 1999, the year indicative of the opioid boom in Appalachia.

Study Selection Process
Review of articles will be carried out in a synchronous process.Decisions on criteria and interpretation of outcomes will be made by the lead researcher in collaboration with the assistant researcher.Since the nature of a scoping review is to collate, synthesize, and describe the coverage of the literature, no assessment of quality will be made but the review will assess whether the study achieved its intended outcomes.The medical librarian will lead the process and source identification for the scoping review.To ensure the standards of a scoping review are upheld, the medical librarian will conduct the searches and provide the results to the senior researcher and research assistant using EndNote.Deduplication will occur using both EndNote and SR-Accelerator Deduplicator (Rathbone, et al., 2015).After deduplication, the team will screen the remaining titles using the stated inclusion and exclusion criteria.The first step of screening will be at the title/abstract level.After title/abstract review, the medical librarian will retrieve full-text of included studies.The lead researcher and research assistant will then conduct full text screening using the inclusion and exclusion criteria.If a disagreement is encountered, the lead researcher and research assistant will discuss and decide whether an article should be included through a review of the larger themes and ideas of the article.Furthermore, inclusion and exclusion criteria will be updated through holistic discussions among the team.

Charting the Data
Excel will be used to assemble and chart data throughout the research process.The first phase will be title-abstract review.The researchers will collectively review title abstracts for inclusion and exclusion criteria.The second phase will be full-text review.The lead researcher and research assistant will simultaneously extract data from the same five randomly selected studies.Reviewing the same articles ensures clarity and enables both researchers to synthesize separate findings into one conclusion.This approach is the most efficient and will limit the amount of time spent reviewing multiple, potentially unnecessary articles.This norming process will follow the title-abstract review and will include the lead researcher and assistant researcher.In order to assure quality and replicability, the lead researcher and assistant researcher will meet to examine each other's extractions.During this meeting, the researchers will come to agreement on extraction methods and details.Afterwards, the remaining included studies will be divided, and extraction will continue until completed.
The data that will be extracted will include: • Author, year of publication, and other background information; • Research approach (quantitative, qualitative, mixed methods, etc.); • State and region of Appalachia as defined by the Health Disparities in Appalachia report (Marshall et al., 2017); • Type of healthcare professional To adequately describe the characteristics of the literature, additional quantitative and qualitative data points may be added by the researchers throughout the process of data extraction and charting.